AJCC TNM STAGING: CHAPTER 1 AND BLANK’S VS X’S

TONYA BRANDENBURG, MHA, CTR

QA MANAGER

KENTUCKY CANCER REGISTRY

WHAT ARE WE DISCUSSING?

What is AJCC Staging

Purpose of staging

General rules for clinical and pathological TNM staging

Anatomic stage/prognostic grouping rules

Using Blanks and X’s when information is unknown

AJCC STAGING

AJCC stands for American Joint Committee on Cancer

Established in 1959 to formulate and publish systems of classification of cancer

Comprised of nineteen member organizations

AJCC STAGING

Classifies the extent of disease at diagnosis based on extent of the primary tumor, involvement of regional LNs, and presence or absence of distant mets

Currently on 8th edition (for cases diagnosed January 1, 2018 forward)

Required by ACoS approved facilities; optional for others

For specified histologies

PURPOSE OF STAGING

Stage of disease

Helps establish prognosis

Is used to determine appropriate treatment, based on the experience and outcomes of previous patients

Stage of disease

Is used in evaluating the results of treatments and clinical trials

Provides a common framework for comparison of patients across treatment centers

Serves as a basis for clinical and translational research

GENERAL RULES

All cases should have microscopic confirmation, even for clinical

classification. In situ cases MUST have microscopic confirmation

Cases without microscopic confirmation can be staged, but survival

should be analyzed separately

GENERAL RULES + SITE SPECIFIC RULES

Assigning T, N, and M categories generally follows general rules. If there are exceptions to the general rules they are outlined in the disease site specific chapter.

The role of the T tumor size and/or contiguous spread are specifically defined for each chapter.

Use of TX category should be minimized as much as possible.

Any T defined

Includes all T categories except Tis

Includes TX and T0

T N M CLASSIFICATION

T describes the primary tumor, and is defined by size or contiguous extension T0, Tis, T1 – T4, TX

N denotes the presence or absence of cancer in regional draining lymph nodes N0, N1 – N3, NX

M denotes the presence or absence of distant spread or metastases M0, M1

TIMING RULES

DISEASE PROGRESSION AND STAGING

Both clinical and pathological staging say to use only the information

before progression to assign the stage

If there is evidence of progression before the start of any treatment, do

not use that information for staging

STAGING AND NEOADJUVANT THERAPY

Neoadjuvant therapy is systemic therapy or radiation therapy given before surgical resection.

Staging assigned after neoadjuvant therapy is indicated by a ‘y’ descriptor

yc - clinical stage after systemic or radiation therapy but prior to surgical resection; this is not currently captured by cancer registries

yp – pathologic stage after systemic or radiation therapy AND surgical resection; this is currently reported in the pathologic stage elements, with the ‘y’ descriptor

REQUIRED NON-ANATOMIC PROGNOSTIC FACTORS

Some AJCC chapters require non-anatomic factors for assigning stage

Clearly defined in each chapter – Also check the SSDIs required to stage list

in the SSDI manual

These are collected separately from T, N, and M and are used to assign stage

groups

There are more of there prognostic factors for staging in the 8th Edition

REQUIRED PROGNOSTIC FACTORS

Cancer registry data collection

Registry must record X or unknown if factor not available

Registry must NOT use lowest category

Registry may NOT assign stage group if factor needed

IS IT STAGEABLE?

STAGING FOR COLON For clinical staging to apply, there must be a suspicion of cancer.

For pathologic staging to apply you must meet one of the following criteria:

Surgical resection per AJCC Colon chapter including polypectomy, segmental resection (ex: sigmoidectomy), partial colectomy, hemicolectomy, total colectomy)

Biopsy of highest T category PLUS biopsy of highest N category. (T4/N2 proven).

Positive histologic confirmation of a metastatic site. (M1 proven).

For post therapy staging to apply you must have systemic and/or radiation therapy followed by surgery

CLINICAL STAGE

Clinical classification composed of;

cT

cN

cM or pM

CLINICAL STAGING

Incorporates info from physical exam, endoscopy, imaging, biopsies, and surgical exploration without resection

Clinical staging is required by ACoS

Expressed as cT, cN, cM

CLINICAL T, N, AND M

How can we determine a clinical TNM stage? Use all information from any of the following obtained BEFORE treatment: Physical examination Imaging Endoscopy and Biopsy Surgical exploration without resection Resection of a single node/sentinel node(s) with a clinical T Lab test or biological markers Any other relevant examinations Any other relevant information before neoadjuvant treatment or surgical

resection

CLINICAL M

cM0

No symptoms or signs of mets

There is no MX category, so it must be M0 or M1 or left blank

Only H&P needed to assign cM0

cM1

Seen on physical exam or imaging

Seen during scopes or operations, but not bx

pM1

Diagnosed by bx

PATHOLOGICAL T, N, AND M

How can we determine a pathological TNM stage?

Use all of the clinical staging information in addition to information obtained in:

Operative findings (surgeon’s statement of findings)

Pathology report (Only 1/3 of the information)

PATHOLOGICAL CLARIFICATIONS

Pathological classification composed of;– pT– pN– cM or pM

pT – in general, resection of primary tumor is required Based on tumor size of extent of contiguous spread Record size to the nearest whole millimeter Ex: 4.5cm = 45, 3.43cm = 34, 6.8mm = 7

Biopsy which allows evaluation of highest T category is adequate to stage, pT can be assigned without resection

PATHOLOGICAL CLARIFICATIONS

pN Regional node assessment for path classification

Number of nodes resected

Requires pathologic assessment of at least ONE node

Minimum number for sufficient sampling is explained in each chapter; however, if fewer than minimum number sampled, you can still assign pN

Usually need pT to code pN

Microscopic eval of highest N category can be used to assign pN, even if T is cT

PATHOLOGICAL CLARIFICATIONS CONTINUED

pM can only be M1 (or 1a, 1b, 1c) or blank

pM0 does NOT exist pM1 special considerations

Requires positive biopsy of metastatic site May be used WITH cT and cN to assign pStage Group Staged as both

Clinical stage IV – cT cN pM1 Pathologic stage IV – cT cN pM1

DEFINITIONS OF PRIMARY TUMOR

TX - Primary tumor cannot be assessed

T0 - No evidence of primary tumor

Tis - carcinoma in situ; intraepithelial or invasion of lamina propria

*Note: Tis includes cancer cells confined within the glandular basement membrane intraepithelial) or mucosal lamina propria intramucosal) with no extension through the musclaris mucosae into the submucosa.

DEFINITIONS OF PRIMARY TUMOR

T1 – tumor invades submucosa

Through the muscularis mucosa but not into the muscularispropria

DEFINITIONS OF PRIMARY TUMOR

T2 – tumor invades muscularis propria

DEFINITIONS OF PRIMARY TUMOR

T3 – tumor invades through the muscularis propria into pericolorectal tissues

DEFINITIONS OF PRIMARY TUMOR

T4a – tumor invades through the visceral perintoneum

DEFINITIONS OF PRIMARY TUMOR

T4b – tumor directly invades or is adherent to other organs or structures

REGIONAL NODESThe ‘N’ category designates the presence or absence of tumor in the regional LNs; increasing numerical involvement based on size, fixation, or invasion of the capsule that surrounds the LN, OR on number/location of involved LNs

DEFINITIONS OF REGIONAL NODES

NX – regional LNs cannot be assessed

N0 – no regional LN metastasis

N1 – mets in 1-3 regional LNs

N1a – mets in one regional LN

N1b – mets in 2-3 regional LNs

DEFINITIONS OF TNM

N1c – tumor deposits in the subserosa, mesentery, or nonperitonealized pericolictissues without regional nodal metastasis

DEFINITIONS OF TNM

N2 – mets in four or more regional LNs

N2a – mets in 4-6 regional LNs

N2b – mets in seven or more regional LNs

DEFINITIONS OF TNM

M component identifies the presence or absence of distant mets

M0 – no distant metastasis

M1 – distant metastasis NOS

M1a – mets confined to one organ or site

M1b – mets to more than one organ/site or the peritoneum

M1c – mets to the peritoneal surface is identified alone or with other site or organ mets (NEW for AJCC 8th Edition)

STAGE GROUPINGS

• Allows grouping of patients with similar prognosis into fewer categories• Useful for data analysis and treatment guideline development• Stage groups summarize the stage information in a manner that is easily

communicated and reproducible

Clinical Stage Group

cT

cN

cM or pM

Pathologic Stage Group

pT

pN

cM or pM

Post Tx Stage Group

PostTxT

PostTxN

PostTXcM or pM

RULES FOR STAGE GROUPINGS WITH AJCC 8TH EDITION

Subcategory info not available to registrar

Assign main category (available in all AJCC tables)

Do NOT assign lower subcategory

Stage group info not available to registrar

e.g., missing subcategory or prognostic factor category

Do NOT assign stage group

Document stage group as unknown

TNM STAGE GROUP

WHEN TO USE BLANKS AND X’S

“X” indicates something was done for T or N Category Code but result was not clear in the test report to assess the primary tumor size/extent or nodal status. “X” does not equal “Unknown”

<blank> indicates no test was performed, patient not eligible to stage, no info available in medical record on staging to determine T or N Category Code

M Category always has to be coded when the patient meets eligibility criteria for staging. There can never be a mX or a blank M category when T and N are coded.

cM0 can be used for clinical no evidence of mets AND for pathological when mets not proven histologically

pM1 is histologically proven mets (bx or resection) and can be used for clinical and pathological

BLANKS AND X CONTINUED Blank X

Blank = info not available OR doesn’t meet staging criteria

• Valid only for TNM categories• Use when you know staging was done, but

info is not in chart• don’t default to X

X = cannot be assessed• Valid only with T and N categories• Not a default• Not equivalent to unknown

Clinical Pathologic

• cTX – patient not examined, no imaging or workup

• cT blank – no access to information when abstracting case

• cT blank – incidental finding at surgery

• pTX – resection performed, but the specimen was lost or destroyed

• pT blank – no surgical resection• pT blank – no access to information when

abstracting case

QUESTIONS?

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